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Leaflet escape in contemporary mechanical valves is an extremely rare and potentially lethal condition. We report the case of a 77-year-old man who presented with embolization of a leaflet from an On-X mitral valve (CryoLife, Kennesaw, GA) with Conform-X Sewing Ring prosthesis (CryoLife) after exercise. The patient recovered completely 6 months after surgery, and he is currently asymptomatic.

A patient was submitted to mitral valve replacement and tricuspid ring annuloplasty. During immediate postoperative course, signs of inferior myocardial ischemia appeared. Acute entrapment of the right coronary artery due to tricuspid ring sutures was confirmed by coronary angiography. The patient was reoperated and a right coronary bypass graft was successfully performed. Tricuspid procedures have shown to be effective and secure with a low rate of complication. Few cases of right coronary artery occlusion have been described and the majority not treated. Exceptional cases of right coronary occlusion related to tricuspid ring annuloplasty have been reported with a favorable outcome, as the case described herein.

Background The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II has been recently introduced to improve mortality prediction in cardiac surgery. We compare the predictive ability of the new EuroSCORE II with that of the original logistic EuroSCORE and we made an evaluation of a sample of our population submitted to major cardiac surgery in the context of a Mediterranean country. Materials and Methods Predicted and observed mortality were recorded in 1,200 consecutive patients undergoing major cardiac surgery at our institution with both logistic EuroSCORE and EuroSCORE II. Patients were grouped according to type of surgery: isolated valvular ( n = 538), isolated coronary ( n = 322), combined ( n = 192), and miscellaneous ( n = 148). Predictive capacity of both scales was compared for overall population and for each group in terms of calibration and discrimination using the observed by expected mortality rate, Hosmer–Lemeshow test, and C-statistic. Results Overall mortality was 6.8%, whereas that predicted by logistic EuroSCORE and EuroSCORE II was 9.7 and 3.7%, respectively. Mortality in our population was higher than mortality expected according to the original EuroSCORE II database. For all groups included in our population, logistic EuroSCORE overestimated mortality and EuroSCORE II underestimated the outcome even more. However, EuroSCORE II showed better calibration than logistic EuroSCORE for overall, valvular, and combined surgery. In contrast, logistic EuroSCORE demonstrated better calibration for coronary surgery. Discrimination capacity was good for both risk scores, but it was superior for logistic EuroSCORE than for EuroSCORE II in all considered subgroups unless combined surgery. Conclusion Mortality in our population was higher than the mortality that would have been expected by the new EuroSCORE II analysis. Although EuroSCORE II has good calibration and discrimination capacity, both are worse than those demonstrated by logistic EuroSCORE. Forthcoming evaluations are necessary when the new model will be widely used.

Spinal cord tissue has a remarkable resistance to infection. An intramedullary abscess is an exceptional complication of infective endocarditis in the post-antibiotic era. We describe the case of a 42-year-old man who presented with fever and cephalea. Two days later, left-side numbness, lack of sphincter control, and a new aortic murmur were noticed. Magnetic resonance imaging demonstrated an 8 ×15-mm intramedullary cervical abscess. Transesophageal echocardiography revealed an aortic valve perforation as a result of infective endocarditis. Conservative management was decided for the intramedullary abscess.

A young male presented with a right parasternal stab wound. The chest radiography was normal and transthoracic echocardiography ruled out pericardial tamponade. He remained hemodynamically stable until three hours later when signs of progressive anemia were observed. Chest computed tomography showed massive right-sided hemothorax. The patient underwent surgery, which revealed an active bleeding atriopleural fistula connecting the right atrium and draining into the right pleura resulting from the negative pressure generated during respiration. This mechanism prevented cardiac tamponade and maintained initial hemodynamically stability. Resumo: Um jovem foi transferido para o serviço de emergência da nossa instituição com uma facada paraesternal direita. A radiografia de tórax foi normal. A ecocardiografia transtorácica descartou a presença de derrame pericárdico. Manteve-se hemodinamicamente estável até ao fim de três horas, após o que o paciente começou a apresentar sinais de anemia progressiva. Foi realizada tomografia computadorizada de tórax que mostrou hemotórax maciço. O paciente foi encaminhado urgentemente para cirurgia cardíaca. Observou-se hemorragia ativa através de uma fístula corte pleural ligando o átrio direito/a aurícula direita e drenagem pleural direita, resultado da pressão negativa da pleura durante a respiração. Este mecanismo impediu o tamponamento cardíaco e explica a estabilidade hemodinâmica inicial. Keywords: Atriopleural fistula, Stab wound, Treatment, Surgery, Palavras-chave: Fístula atrio-pleural/aurículo pleural, Facada cardíaca, Tratamento, Cirurgia

A 70-year-old woman was admitted to our institution due to a two-month history of progressive dyspnoea. Physical examination did not revealed abnormalities. Electrocardiogram showed sinus tachycardia. Transthoracic echocardiography demonstrated a giant mobile undefined mass located on the left atrium (LA). The tumour prolapsed on the left ventricle through the mitral valve (MV) during diastole (Fig. 1A–C). The absence of MV regurgitation was detected. Cardiac surgery was scheduled. Under general anaesthesia and continuous transoesophageal echocardiography (TEE) monitoring, a medium sternotomy was performed. Standard cardiopulmonary bypass was established through bicaval cannulation. Access to the LA was made via septal-superior approach. An encapsulated yellowish-red 7 × 6 cm mass arose from the LA. It was attached to the LA septum next to the anterior leaflet of MV. The tumour was completely excised (Fig. 1D, E). However, at the moment of weaning from cardiopulmonary bypass, intraoperative TEE revealed severe MV regurgitation that was previously unknown. Cardiopulmonary bypass was established again to access the LA. No clear MV annulus dilatation or leaflet abnormalities were detected. MV annuloplasty was decided. After second weaning of cardiopulmonary bypass, TEE confirmed the absence of MV regurgitation. Pathology determined myxoma diagnosis. The patient was discharged uneventfully, eight days postoperatively. Concomitant MV regurgitation and the presence of LA myxoma have been previously reported. The causes are related to the size and movement of the tumour interfering with transmitral valve flow, masking MV regurgitation. Moreover, mechanical dilatation of mitral annulus secondary to the presence of an LA tumour may lead to mitral regurgitation. Lesion of MV leaflets or dysfunction of the posterolateral papillary muscle has also been reported. Evaluation of MV competence can be challenging in the context of an LA mass because the absence of MV insufficiency in the preoperative examination should not be taken as a reliable predictor of normal valve function. The role of echocardiography on diagnosis is crucial. Preoperative echocardiography should focus on valve dysfunction to separate tumour-related and unrelated valvular pathologies and their severity. A careful evaluation of MV during resection of myxoma or cardiac tumour is mandatory. Intraoperative and postoperative echocardiography to assess correct valve function and to discard valve regurgitation following tumour resection is also decisive. Association of MV annuloplasty or MV replacement needs to be considered when at least moderate MV regurgitation is detected on preoperative or postoperative echocardiogram, because future evolution or mitral regurgitation is unknown and remodelling does not always occur. Figure 1. A. Transoesophageal echocardiography apical four-chamber view showing left atrial myxoma through mitral valve (MV); B, C. Transoesophageal echocardiogram Doppler colour focusing on MV regurgitation. A 7 × 6 cm mass attached to the interatrial septum and protruding into the left ventricle is shown; D, E. Surgical specimen that exposes tumour appearance. Intratumoural heterogeneity is patent, with haemorrhagic and calcification areas in its interior A B C

Herein we present the case of an 82 year-old patient undergoing cardiac surgery for mitral valve replacement. Fifteen years earlier, the patient had undergone surgery to replace his aortic valve, so that it was now a cardiac reoperation. Through sternotomy, and release of pericardial adherences, there was an accidental opening of a small portion of the peritoneum, proceeding to repair with simple suture. Postoperatively, the presence of pneumoperitoneum alarmed about the possibility of an intra-abdominal complication but it was subsequently discarded with recent surgical process. Through this article we review what the pneumoperitoneum consist, its causes and management, as well as highlighting possible etiologies sometimes not considered as a recent cardiac surgery, simply because the patient in found in different contexts and we do not think about those possibilities.

We report on a 77-year-old woman in whom percutaneous left atrial appendage (LAA) closure was performed. The patient had a left atrial myxoma resection 3 years previously, and 2 years later, she suffered a transient ischemic attack. Atrial fibrillation was detected and anticoagulation therapy was established. An episode of intracranial bleeding forced interruption of anticoagulation. Thus, percutaneous LAA closure with an Amplatzer Amulet LAA Occluder (St Jude Medical) was proposed. During the procedure, the LAA occluder migrated and became trapped in the mitral valve. Secondary massive mitral regurgitation and hemodynamic instability forced emergent cardiac surgery. Successful removal of the Amplatzer Amulet LAA Occluder was achieved.

We describe a curious congenital variation of human aortic arch (AA) branching pattern termed the “bovine aortic arch”. Rather than arising directly from the AA as a separate branch as occurs in the most common AA branching pattern, the left common carotid artery moves to the right and merges from the brachiocephalic trunk. It is the normal AA branching pattern presented in a number of animals (canines, felines or Macaque monkeys) but it has nothing to do with anatomy of AA in ruminant animals, including cattle and buffalo. That is why it is one of the most widely misnomers used in medical literature whose origin is nowadays unknown.

A 78-year-old woman was admitted to our institution with progressive dyspnea. She had previously been diagnosed with rheumatic heart disease and had undergone cardiac surgery for mechanical mitral valve replacement ten years previously. Transesophageal echocardiography revealed blockage of the mechanical prosthesis and the patient was scheduled for surgery, in which a thrombus was removed from the left atrial appendage. A partial thrombosis of the mechanical prosthesis and circumferential pannus overgrowth were concomitantly detected. Prosthetic heart valve blockage is a rare but life-threatening complication, the main causes of which are thrombosis and pannus formation. The two conditions are different but both are usually misdiagnosed. Two concurrent mechanisms of prosthesis blockage were found in this patient. Resumo: Uma mulher de 78 anos de idade, foi admitida na nossa instituição com dispneia progressiva. Foi-lhe previamente diagnosticada doença reumática, tendo sido submetida a cirurgia cardíaca de substituição de válvula mitral por prótese mecânica há dez anos. O ecocardiograma transesofágico revelou um bloqueio da prótese mecânica. A paciente foi referida para a cirurgia, tendo sido removido um trombo do apêndice atrial esquerdo. A trombose parcial de prótese mecânica e o crescimento circunferencial de pannus ocorreram concomitantemente. O bloqueio das válvulas cardíacas protésicas é uma complicação rara mas potencialmente fatal. As principais causas são a trombose ou formação de pannus. As duas condições são diferentes, mas em regra erradamente diagnosticadas. Nesta paciente foi detetado um duplo mecanismo de bloqueio de prótese. Keywords: Mitral, Prosthesis, Thrombosis, Pannus, Mechanical valve dysfunction, Palavras-chave: Mitral, Prótese, Trombose, Pannus, Disfunção valvar mecânica